Deteksi Dini Gangguan Kognitif Akibat Gangguan Vaskular

DETEKSI DINI GANGGUAN KOGNITIF AKIBAT

GANGGUAN VASKULARDiatri Nari Lastri

Divisi NeurobehaviorDepartemen Neurologi FKUI-RSCM

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Introduksi

30/01/2011 PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR ASTON RASUNA JAKARTA

Populasi usia lanjut:1 sampai 2% menjadi demensia pertahun

Populasi Mild Cognitive Impairment population:6 to 25% per tahun menjadi dementia50% dalam 3-5 tahun menjadi demensia

Diagnosis dini gangguankognitif sangat penting untuk mencegah penurunan kognitif yang lebih buruk lagi

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Introduksi

• Lebih dari 34% kasus demensia menunjukkan gambaran patologis vaskular yang bermakna.1

• Faktor risiko vaskular2

– Risiko menjadi CVD– Risiko terjadinya gangguan kognitif

• Strong interaction between cerebrovascular and AD pathologies.Individuals having both frequently show greater cognitive impairment than those having either pathology alone.3

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ASTON RASUNA JAKARTA

3. J Am Geriatr Soc. 2004;52:1442-1448 Ann Neurol. 2005;57:98-103

1. Arch Neurol. 2003; 60:569-575 J Neurol Sci.2004;226:13-17

2. Arch Neurol. 2005; 62:1556-1560 J Am Geriatr Soc. 2005;53:1101-1107

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Vascular Cognitive Impairment

“Vascular Cognitive Impairment” (VCI) gangguan kognitif yang disebabkan atau

berhubungan dengan faktor-faktor vaskular

Faktor risiko vaskular dapat dikendalikan

Kemungkinan untuk mencegah, memperlambat, dan menghentikan VCI

dementia30/01/2011

PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR ASTON RASUNA JAKARTA

Hachinski VC, Bowler JV. Vascular Dementia. Neurology. 1993;43:2159-2160Bowler JV, HachinskiVC, eds. Vascular Cognitive Impairment. Oxford University Press; 2003

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• Individu dengan faktor risiko vaskular (hipertensi, diabetes, gagal jantung, dan dislipidemia) sering mengalami gangguan fungsi kognitif dibandingkan individu normal

• Penyandang hipertensi memiliki skor kognitif yang lebih rendah dibanding individu normal

• Kekerapan gangguan kognitif penyandang hipertensi meningkat 7- 9% bila tekanan darah tidak terkontrol

• Sidi P, Puskesmas Tebet dan Pasar Minggu: 84% penyandang hipertensi menunjukkan gangguan kognitif non demensia (MMSE dan CERAD)


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Vascular Cognitive ImpairmentThe Continum of Cognitive Decline


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• Gangguan Kognitif karena CVD• Subcortical Ischemic Vascular Disease (SIVD)– Gambaran yang tersering– Meningkat dengan pertambahan usia dan faktor risiko

vaskular

• Gambaran SIVD:– Gangguan fungsi eksekutif / fleksibilitas mental– Perlambatan kognitif – Depresi dan Apati


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NINDS Neuroimaging Criteria for VaD

• Topography– Large vessel stroke– Extensive white matter change– Lacunes (frontal/basal gangglia)– Bilateral thalamic lesions

• Severity– Large vessel lesion of dominant hemisphere– Bilateral strokes– WML > 25% white matter


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Brain Imaging of VaD

3 types of VaD

Multiple large vessel infarcts

Bilateral strategic thalamic infarcts

Binswanger’s disease



Hiperintensitas Subkortikal

None Mild Moderate Severe

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• Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) and hereditary cerebral hemorrhage with amyloidosis-Dutch type (HCHWA-D).

• CADASIL is a syndrome of subcortical small vessel disease– lacunar strokes– Migraine– dementia

• The disease results from mutations in the Notch 3 gene which is normally expressed in vascular smooth muscle cells and pericytes (including those of the cerebral vasculature)


VaD: A Heterogeneous DisorderCardiovascular Risk Factors

Hypertension Diabetes Genetics Hypercholesterolemia Heart Disease

Ischemic Damage to Cerebral Vasculature

Multiple Distinct Pathologies

Large Vessel Infarcts Small Vessel Infarcts Hemorrhage Hypoperfusion

• Strategic Single Infarcts• Multi-infarct Dementia

• Multiple Lacunar• Binswanger’s Disease• CADASIL

• Chronic SDH• SAH• ICH

• Global (e.g., cardiac arrest)

• Hypotension

Final Common Pathway

Damage to critical cortical and subcortical structures Cholinergic

transmission

Damage/interruption of subcortical circuits and

projections

VaD Erkinjuntti T. CNS Drugs, 1999.30/01/2011 12PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR ASTON RASUNA JAKARTA

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Neurological signs and symptoms

VCI/VaD: Pathology and Clinical Presentation

Large vessel disease Small vessel disease

Lesion location Large cortico-subcortical infarcts

Subcortical infarcts in strategic locations (e.g., thalamus)

Focal40% No focal signs or mild UMN signs (e.g., arm drift, etc.)

Dementia-related changes

Pathology

Common Classic

Preserved until latePersonalityInsight Affective/mood disturbances

Retained until lateLess common(although some depression)

Change

Executive dysfunction (slowing, initiation, planning, organizing, sequencing, monitoring, set shifting, abstraction, judgement)

Depression, apathy, anxiety,emotional lability

Memory impairment: cortical dysfunction (aphasia, apraxia,agnosia, visuospatial dysfunction)

Cognition Memory impairment

Can be impaired

Cummings JL. Dementia, 1994.30/01/2011PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR


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Diagnostic Approach: Clinical Evaluation• Demographics

The minimum data: sex, birth date, race/ethnicity and education

• InformantBasic information regarding the informant’s demographics

• Family historyFirst degree relatives for a history of stroke, vascular disease or dementia

• Health historyHistorical question concerning cardio/cerebrovascular conditions, hypertension, hyperlipidemia, DM, alcohol-tobaco use, physical inactivity, and medication

• Evaluation– Individual general health– Changes in memory, speed of thinking and acting, or mood– Functional abilities instrumental activities of daily living



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Diagnostic Approach of VCI

Canadian Consensus Conference on Dementia:

– Memory Complaints should be evaluated and the individual followed to assess progression (B)

– Complaints should be considered very seriously if confirmed by caregivers / informants. Cognitive assessment and careful follow-up is recommended (A)

Any Memory Concerns Expressed by the Caregivers Should be Comprehensively Evaluated



Petterson: Can J. Neuro Sci; 28 (Suppl 1) 5:3-16

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Diagnostic Approach of VCISign and Symptoms

Physical Neurologic Deficits• Disturbances of gait (slow

and unsteady)• Hyperreflex, extensor

plantar response• Hemiparetic• Hemisensory deficits• Visual problems• Pseudobulbar syndrome

(dysarthria, dysphagia, etc)

Mental Status• Level alertness• Orientation• Attention, cooperation• Language• Memory: recent memory,

remote memory• Visuospatial• Executive Function• Delusions, hallucination,

mood



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NEUROPSYCHOLOGICAL BATTERY FOR VCI

• There is no generally accepted test battery for identifying or classifying patients with VCI

• Deficits:– Large vessel cortical strokes

• Region specific syndromes: aphasia, apraxia, amnesia

– Subcortical small vessel disease• Subtle and temporally progressive deficits• Deficits in”strategic” processing and speed : attention, planning, memory

• Patients may perform :– normally on simple tasks – reveal deficits as tasks increase in complexity

• Neuropsychological testing for VCI testing executive function

Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir HachinskiStroke 2006;37;248-255.



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Criteria for Neuropsychological Test Selection

The pattern of VCI cognitive deficits may include all cognitive domains, specifically executive function:– Slowed information processing– Impairment in the ability to shift from one task to another– Deficits in the ability to hold and manipulate information

(i.e., working memory)

Neuropsychological protocols must therefore sensitive to wide range of abilities and especially attuned to the assessment of executive function

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Stroke 2006;37;2220-2241PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR


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• There is no generally accepted test battery for identifying or classifying patients with VCI

• Deficits:– Large vessel cortical strokes

• Region specific syndromes: aphasia, apraxia, amnesia

– Subcortical small vessel disease• Subtle and temporally progressive deficits• Deficits in”strategic” processing and speed : attention, planning, memory

• Patients may perform :– normally on simple tasks – reveal deficits as tasks increase in complexity

• Neuropsychological testing for VCI testing executive function

Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir HachinskiStroke 2006;37;248-255.



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Fungsi Eksekutif

• Melibatkan area frontal – subkorikal

• Fungsi:– Inisiasi– Planning– Shifting of idea– Abstraksi– Problem solving– Inhibisi, dll

• Kemampuan kognitif kompleks (tingkat tinggi)



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• MMSE is often insensitive to the effects of subcortical small vessel disease, particularly in the earlier stages because the MMSE is to a great deal dependent on over learned abilities, which are relatively spared in VCI.

• Tests that would be most sensitive to VCI are those that require strategic processing: – verbal learning tests

particularly ones that include recall as well as recognition measures VCI patients generally perform better overall on tests of verbal recall than do AD patients, so that these tests cannot be considered selective for VCI

– verbal fluency tests which also are considered measures of strategic processing VCI patients performed less well on these tests than did AD patients

Stroke 2006;37;248-255.

Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir Hachinski



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Canadian Consensus Conference on Dementia:

– Memory Complaints should be evaluated and the individual followed to assess progression (B)

– Complaints should be considered very seriously if confirmed by caregivers / informants. Cognitive assessment and careful follow-up is recommended (A)

(Patterson: Can J. Neuro Sci 2001; 28 (Suppl. 1) S 3-16).

Any Memory Concerns Expressed by the Caregivers Should be Comprehensively Evaluated



Cognitive profilesVascualar Dementia/VCI

• Executive problems• Attention• Psychomotor speed• Emotional lability

Alzheimer’s disease/MCI Anterograde

memory Spatial abilities Gait and motor OK Apraxia

Aphasia Depression

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Screening for VCI/VaD

Dementia screening tools (AD):

MMSE

MOCA

Clock drawing

Trails B

Luria kinetic melody (hand test)

Questioning of patient/caregiver about activities of daily living

Identification of symptoms of executive dysfunction



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Montreal Cognitive Assessment (MOCA)

• Comprehensive: Many more domains than MMSE (good for AD and non AD)

• Minor adjustment for education (add 1 point if ≤ grade 12)

• Much better discrimination Normal vs MCI and Dementia ≥ 26 < 26 < 26

(usually 21-25) (usually < 20) function OK function affected



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MoCA-InaPenelitian Departemen Neurologi FKUI-RSCM (2009)• Uji validitas dan Reliabilitas Montreal Cognitive Assesment Versi

Indonesia (MoCA-INA): Dr. Nadia Husein (dr. Sylvia FL, dr. Yetty R)

• Uji Validitas (transkultural) – Penamaan:

• Singa Gajah

– Memori:• Beludru Sutera• Aster Anggrek• Gereja Masjid

– Kelancaran berbahasa: • F S

– Modifikasi pengulangan kalimat• Reliabilitas

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a method for evaluating psychomotor function by measuring how quickly a subject can insert pegs into

Grooved Pegboard Test

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Anatomical basis• The cingulate cortex has been

related to the processing of the Stroop effect

• EEG and Functional neuroimaging studies of the Stroop effect : – have consistently revealed

activation in the frontal lobe– more specifically in the anterior

cingulate cortex and dorsolateral prefrontal cortex

two structures hypothesized to be responsible for conflict monitoring and resolution.[

STROOP TEST

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http://en.wikipedia.org/wiki/Stroop_effect

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• The Trail-making test is a neuropsychological test of visual attention and task switching.

• The task requires a subject to 'connect-the-dots' of 25 consecutive targets on a sheet of paper or computer screen.

• The goal of the subject is to finish the test as quickly as possible, and the time taken to complete the test is used as the primary performance metric.

TRAIL MAKING TEST A


http://en.wikipedia.org/wiki/Connect_the_dots

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• Associated with many types of brain impairment; in particular frontal lobe lesions

• The task requires a subject to 'connect-the-dots' in which the subject alternates between numbers and letters (1, A, 2, B, etc.).

• The goal of the subject is to finish the test as quickly as possible, and the time taken to complete the test is used as the primary performance metric.

TRAIL MAKING TEST B


http://en.wikipedia.org/wiki/Connect_the_dots

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ROCFT• Planning

Alternating pattern • Shifting of Idea

Luria kinetic melody (hand test)

• Keterampilan psikomotor

FUNGSI EKSEKUTIF


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• Pemeriksaan skrining neuropsikologi multi domain• 15 pertanyaan:

– Atensi/konsentrasi– Memori– Visuospasial– Bahasa– Fungsi eksekutif

• Waktu: 20 menit• Total skor 0-7: Normal

Total skor ≥8 : Gangguan kognitif

SKRINING TES LURIA NEBRASKA (STLNB)


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SIMPULAN

• Faktor risiko vaskular merupakan risiko gangguan kognitif

• Diagnosis dini gangguan kognitif sangat penting untuk mencegah dan memperlambat terjadinya demensia



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TERIMA KASIH

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Documents

Deteksi Dini Gangguan Kognitif Akibat Gangguan Vaskular